Vertebral osteoporosis often causes failures in spinal instrumentation surgery of older patients. We investigated the reliability of lumbar DXA and the influences of spondylitis, aortic calcification, and prevalent fractures. The subjects in this study were 125 patients admitted to our hospital for osteoporotic fractures from 2018 to 2022, 64 with femoral and 61 with spinal fractures. The mean age was 82.8 years. We analyzed L1-L4 and femoral neck DXA and spinal CT, grading spondylitis with the Kellgren-Lawrence scale and aortic calcification with its severity. The diagnostic accuracy of osteoporosis was 78% at femoral DXA but 39% at lumbar, as a T-score was -2.5 or lower. The discordance between lumbar and femoral DXA, defined by Leslie,2011 was 45%. We found KL≧2 in 86%. In KL≦2 (69 patients) and KL≧3 (56 patients), the mean lumbar T-score were -2.3 and -1.7 (p<0.05), respectively. 92% had aortic calcification, including 50 patients with none or minor and 75 with major ones. The mean lumbar T-scores were -2.4 and -1.8 (p<0.05). The existing grade 1 or higher fractures on semiquantitative evaluation at L1-L4 localized in 71% of all patients, averaging 0.7 fractures per patient. Our study indicated that the diagnostic accuracy was low even in patients with osteoporotic fractures, as spondylitis and aortic calcification were the leading causes. And the high ratio of prevalent fractures undermined the reliability of the measurements. Before spinal surgery, we should evaluate the lumbar BMD rather than the femur, but the lumbar DXA is unsuitable for diagnosing osteoporosis in older patients.

Introduction: Since 2006, the idea of Value-Based Health Care (VHBC) has gained traction, introducing the need for value from a patient’s view as well as a health system’s view. Arthroplasty registers and their international body (ISAR) seek to improve outcomes for individuals receiving joint replacements; at face value, register data forms part of a VBHC approach. This study explores the symbiosis between high-quality register data and VBHC with a view to disambiguation of the two approaches. Material and methods: The research project uses exploratory, semi-structured interview methods with a sample of regionally, nationally, and internationally recognised register experts. Participants are provided with some contextual questions prior to the interview. Results: The link between arthroplasty registers and improved patient outcomes (such as pain, function, mortality, reoperations or other adverse events) is supported by the initial outcomes of this study. Pilot interviews have revealed the importance of clinician-led registers in the implementation of an evidence-based practice, providing stakeholders with improved decision-making protocols. Improved decisions on effective implant choices and pre- and post-operative care regimes have led to improved outcomes in three domains–for the patient, the clinician and the health system. These are interwoven but include improved independence, reduction of revision procedures, reduction of opioid use, and cost-savings. Conclusion: Initial results suggest that arthroplasty registers inform stakeholders, improves evidence-based decisions about arthroplasty surgery, supports a link between the principles of VBHC and the evidence-generating potential of arthroplasty registers, outlining a common purpose in improving outcomes and value for both patients and society.

Introduction: The existence of a “minority tax,” defined as the burden of extra responsibilities placed on minorities relative to non-minorities of the same position, has been documented across various fields, including and beyond medicine. This study sought to quantify the types and extent of the minority tax faced by minority orthopaedic surgeons, as well as evaluate the degree to which this work was recognized and/or compensated. Methods: A survey was distributed via email and social media through the international network of associations, collectives, and societies of minorities in orthopaedics. The survey assessed demographics, involvement in diversity, equity, and inclusion (DEI) work, and characteristics of this work. Results: 290 orthopaedic surgeons from 37 countries completed the survey. Respondents were 91% female and 9% LGBTQ+. Fifty-seven percent reported engaging in DEI work. When asked if they worked on nights, weekends, or workdays, 22% indicated all three, and 30% indicated they worked on personal vacations. Only 18% had a title associated with their DEI work, with only one respondent (4%) indicating this was a paid position. Forty-six percent reported spending their own money on DEI work. Conclusions: This study is the first, to our knowledge, to quantify the minority tax in orthopaedic surgery. The results demonstrate that more than half of minority-identifying orthopaedic surgeons engage in DEI work, which involves a substantial investment of time and financial resources. Greater attention should be paid to deficits in compensation and recognition, with increased advocacy for fairness and equity for orthopaedic surgeons engaged in DEI work.

Background: Sickle cell disease is a common hemoglobinopathy in Iraq generally and Basrah province specifically. The sacroiliac joint is one of the underestimated causes of lower back pain, and it is involved in sickler patients, but this joint dysfunction is rarely reported in the literature.
Objectives: How often the sacroiliac joint is involved in sickler patients and to describe its clinical and radiological features.
Methods: A descriptive cross-sectional study was conducted for the period from the 1st of October 2021 to the 1st of December 2022. A prepared questionnaire was used for data collection, in which focused history and clinical examination for all patients with sickle cell disease with or without lower backache. Radiological imaging was offered to all patients and MRI to selected patients.
Results: 217 patients with sickle cell disease were involved. Sixty two (28.6%) of patients with sickle cell disease have lower back pain, and it is most commonly of moderate severity 43 patients (19.8%). In 36 (16.6%) of patients, limping and antalgic gait are documented. The FABER test is positive in 43 (19.8%) of patients with sickle cell disease and lower backache. X_ rays are positive in about one fifth of the enrolled patients in the study (20.3%) . MRI was able to detect an abnormality in 19 (64.2%) of the examined cases, and the most common MRI finding is subchondral sclerosis.
Conclusions: The sacroiliac joint is relatively common involved in sickle cell disease and the diagnosis is also vague.

Background: Transcutaneous CO2 application promotes fracture healing and osteogenesis via angiogenesis. In the present study, we utilized a rat hindlimb suspension model to investigate the preventive effect of this treatment on disuse atrophy of bone and muscle.
Methods: Twenty-one 11-week-old male Sprague-Dawley rats were randomly divided into the hindlimb suspension (HS), hindlimb suspension with transcutaneous CO2 application (HSCO2), and control groups. In the HS group, a 30-degree head-down tilt was applied so that their hindlimbs did not touch the ground. In the HSCO2 group, which had similarly suspended hindlimbs, hydrogel was applied to both hindlimbs and sealed in a polyethylene bag filled with 100% CO2 gas for 20 minutes five times a week. After 3 weeks, radiographic and histologic assessments were performed.
Results: The myofiber cross-sectional area of the gastrocnemius in hematoxylin-eosin staining was decreased in the HS group compared to the control group and increased in the HSCO2 group compared to the HS group. On microcomputed tomography, the femurs in the HS group showed significant bone atrophy while improvement was noted in the HSCO2 group. Histological analysis of the proximal tibia showed more adipocytes in the HS group and fewer adipocytes in the HSCO2 group, similar to the control group. TRAP staining showed decreased osteoclast surfaces in the HSCO2 group compared to other groups. ALP staining decreased and increased osteoblast surfaces in the HS and HSCO2 groups, respectively.
Conclusion: Transcutaneous CO2 application is effective in preventing disuse bone and muscle atrophy in a rat hindlimb suspension model.

Rheumatoid arthritis (RA) is a chronic inflammatory joint disorder that causes systemic inflammation, autoimmunity, and joint abnormalities that result in permanent disability. Although current therapeutic strategies, such as non-steroidal drugs or anti-cytokine biologics, hold promise for the treatment of RA, their side effects and clinical response rates remain unsatisfactory. Exosomes are released from stem cells as well as by cells in the inflammatory microenvironment, and they are effective in the release of anti-inflammatory mediators by modulating gene-expression. This study aimed to explore the effects of exosomes derived from human foreskin stem cells on inhibiting M1 macrophage polarization, reducing chondrocytes apoptosis, and inhibiting extracellular matrix degradation during RA degeneration. Cell viability, apoptosis, inflammation factors, and protein levels were detected by CCK-8, flow cytometry, enzyme-linked immunosorbent assay and western blot, respectively. The levels of tumor necrosis factor-α (TNF-α), interleukins (IL)-6, IL-1β and matrix metalloproteinases were analyzed using enzyme-linked immunosorbent assay. In vitro results revealed that exosomes inhibited the expression of IL-6, IL-1β, and TNF-α, as well as promoted the proliferation of chondrocytes cells. The flow cytometry results show that the expression of CD86, a surface marker of M1 macrophages, was decreased, confirming that the polarization of M1 macrophages was inhibited. Our research demonstrates that effective treatment with exosomes derived from human foreskin stem cells enhances proliferation of chondrocytes, mediates the regulation of anti-inflammatory functions of macrophages, inhibits degradation of the extracellular matrix, and provides a new target and natural medical candidate for future RA treatments.

Introduction: Pelvic reconstructions after massive bone resections are among the most challenging practices in orthopedic surgery. Whether the bone gap results after a trauma, a tumor resection, or it is due to a prosthetic revision, it is mandatory to reconstruct pelvic bone continuity and rebuild the functional thread that connects spine and hip joint. Several different approaches have been described in literature through the decades to achieve those goals. To this date, 3D printed implants represent one of the most promising surgical technologies in orthopedic oncology and complex reconstructive surgery. We present our experience with 3D printed custom-made pelvic prostheses to fulfill bone gaps resulting from massive bone loss due to tumor resections.
Methods: We retrospectively evaluated 17 cases treated with pelvic bone reconstruction using 3D-printed prostheses. Cases were evaluated in terms of both oncological and functional outcomes.
Results: At the last follow-up, local complications were found in 6 cases (36%): in 4 (23.5%) of them the cause was a local recurrence of the disease, whereas only 2 (12.5%) had non-oncologic issues. The mean MSTS score in our population increased from 8.2 before surgery to 22.3 at the latest clinical control after surgery.
Conclusions: Our data confirm the idea that 3D printing and custom-made implants are promising technologies that one day could shape the future of orthopedic oncology and reconstructive surgery.

Objective: This study reveals the dietary characteristics and intestinal flora of postmenopausal women with normal
bone mass and postmenopausal osteoporosis patients.
Methods: Fecal microbiota profiles were determined from 99 individuals with osteoporosis (n = 55), and an age- and gendermatched group with normal BMD (n = 44). The shallow shotgun sequencing was applied to explore the association of postmenopausal osteoporosis with the composition and structure of the gut microbiota. Participants were also given a food frequency questionnaire to further clarify the relationship between diet, gut microbiome, and postmenopausal osteoporosis. Results: There was a significant positive correlation between BMI and BMD. Food frequency questionnaire showed that a high intake of red meat was a risk factor for osteoporosis. In contrast, a high intake of vegetables and yogurt was a protective factor. The fecal bacteria comprised 2671 species, 891 genera, 292 families, 152 orders, 80 classes, and 29 phyla. Postmenopausal osteoporosis patients had a higher gut microbial richness. Relative abundance analysis showed that at the species level, the significantly altered bacteria species were counted. Relative abundance analysis showed that B. thetaiotaomicron, B. ovatus, B. stercoris, R. Inulinivorans, and A. hadrus were among the top 30 abundant bacteria species and significantly increased in the Op group (p < 0.05). Lefse analysis showed that Methanobrevibacter, Rhodococcus, and Anaerostipes were significantly enriched in the Op group (LDA>2). Conclusion: We reveal the complete gut microbiota characteristics of postmenopausal women with osteoporosis. We show crosstalk between diet, gut microbiota, and BMD.